Provider Demographics
NPI:1972932317
Name:KHAISER, MEGHAN JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:JEAN
Last Name:KHAISER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:JEAN
Other - Last Name:SRENIAWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2214 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604
Mailing Address - Country:US
Mailing Address - Phone:309-680-7634
Mailing Address - Fax:309-676-5506
Practice Address - Street 1:2321 N WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-5613
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-681-4681
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant